1. Thomas Hess, Cathy BSN, RN, CWOCN

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Wound bed preparation is a multistep, organized, and holistic process to optimize wound healing. Goals of wound bed preparation include removing necrotic or fibrinous tissue, reducing the total number of senescent or abnormal cells, decreasing the level of exudate, decreasing the bacterial load, and increasing granulation tissue. When these goals are met, the final phase of healing-wound closure-can occur. After assessing the patient and the wound, the clinician can develop a plan of care that focuses on actions that will prepare the wound bed for healing.


Bacterial Balance

Most wounds contain a variety of organisms. The strategy of bacterial balance stresses the need for the clinician to recognize when the bacterial load has increased through a change in granulation tissue appearance and exudate amount.


In a chronic wound that is healing, the level of bacteria present is referred to as contamination/colonization-a steady state of replicating organisms that maintain a presence in the wound but do not cause injury or delay the wound healing process.


For a patient with contamination/colonization, the clinician should select topical therapies that can create and maintain a moist wound environment. Adjunctive therapies, in combination with absorbent topical management products, may assist in achieving wound healing. For example, compression therapy may be combined with a moist wound dressing in a patient with a venous ulcer. Patient education for the care of the chronic wound is paramount to achieving and maintaining a healed wound.


The next level of bacterial load is critical colonization, characterized as replicating (infectious) organisms present in the wound that begin to cause a change in the wound's status. The clinician may see understated clinical features in the wound's appearance, including foul or excessive odor, absent or abnormal granulation tissue, change in color of the wound bed from previous evaluations, delayed healing, friable granulation tissue, severe or increased pain at the wound site, excessive or increased serous exudate, serous exudate with concurrent redness of surrounding periwound wound edges, and tunneling or pocketing of the wound.


The clinician should select topical therapies that will reduce the bacterial load, contain exudate, and improve the wound's granulation tissue. As with contamination/colonization, the patient may benefit from adjunctive therapies, such as compression therapy, in combination with absorbent topical management products. Educate the patient to help achieve and maintain a healed wound.


A wound infection can be characterized as organisms present in the wound and surrounding soft tissue that results in a host response and leads to nonhealing or decline of the wound (ie, increase in size, pain, etc). Signs and symptoms include periwound and soft tissue edema, periwound and soft tissue erythema, fever, foul odor, severe or increasing pain at the wound's site, tenderness at the wound and periwound site and surrounding soft tissue, excessive and/or purulent drainage, warmth of the surrounding soft tissue and periwound skin, and evaluated white blood cell count with an increase in newly developed cells (bands).


Appropriate systemic (oral or intravenous) antibiotics used with select topical therapies can be used to treat the bacterial infection, contain exudate, and improve the wound's granulation tissue. Consider using adjunctive therapies, such as compression therapy, in combination with absorbent topical management products, and educate the patient about achieving and maintaining a healed wound.



Through the process of removing devitalized tissue and foreign material from a wound, the clinician may also be removing senescent and nonmigratory cells in and around the wound. Removing these materials may contribute to the release of available growth factors in the wound.


Debridement techniques include autolytic, biosurgery, enzymatic, mechanical, and surgical. The type and frequency of the debridement technique chosen depend on the overall patient condition and treatment plan.


Exudate Management

Chronic wound fluid inhibits cell growth in culture and is interconnected with barriers to healing, including necrotic tissue and bacterial imbalance. Controlling the amount of exudate may improve healing by improving migration of key cells, such as keratinocytes, fibroblasts, and endothelial cells, as well as matrix metalloproteinases and other proteases.


The type of exudate management device used will depend on the etiology of the wound and may include compression therapy, mechanical devices/products, or absorptive dressing management.


Source: Clinical Guide: Skin and Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.